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A diagnosis of ADHD can be made by a general practitioner without a comprehensive assessment.
False
Drug treatments are the primary treatment plan for ADHD.
False
Methylphenidate is a central nervous system (CNS) depressant.
False
Dexamfetamine has a larger evidence base from trials compared to methylphenidate.
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Lisdexamfetamine is not a prodrug.
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Methylphenidate and dexamfetamine are Schedule 1 Controlled Drugs.
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Prescriptions for methylphenidate and dexamfetamine should be written for a maximum supply of 60 days.
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Dexamfetamine is less likely to be diverted and misused compared to methylphenidate.
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Lisdexamfetamine is broken down in the liver.
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Lisdexamfetamine has a higher abuse potential compared to methylphenidate.
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Atomoxetine is more effective than stimulants in treating ADHD.
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Lisdexamfetamine has been established as superior to placebo in children and adolescents.
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Bupropion has not been found to be efficacious in treating ADHD.
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Guanfacine is not licensed for use in children with ADHD in the UK.
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Tricyclic antidepressants are recommended for use in clinical practice.
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Modafinil has been found to be effective in adults with ADHD.
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Second-generation antipsychotics are recommended for treating ADHD.
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ADHD first diagnosed in adult life is not compatible with ICD-11 and DSM-5.
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Methylphenidate is considered a second-line choice of medication in adults with ADHD.
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Dexamfetamine is not used to treat ADHD in adults whose symptoms are responding to lisdexamfetamine.
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The dosage of guanfacine for children weighing 6-12 kg is initially set at 1mg once daily.
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The maximum per dose of guanfacine for adolescents weighing 58.5 kg and above is 6mg.
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For adolescents aged 13-17 weighing between 41.5-49.4 kg, the maximum per dose of guanfacine is 5mg.
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Initially, guanfacine should be administered at 1mg once daily for all weight categories listed.
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For a 7-year-old child weighing 10 kg, the maintenance dose of guanfacine would range from 0.5-1.2mg/kg once daily.
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Guanfacine dosages should be adjusted in steps of 1mg every two weeks.
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For adolescents aged 13-17 weighing between 49.5-58.4 kg, the maximum per dose of guanfacine is 6mg.
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Guanfacine is not available for children weighing less than 6 kg.
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For children weighing 13-17 kg, the initial dosage of guanfacine is 2mg once daily.
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The maintenance dose of guanfacine for all weight categories listed should range between 0.05-0.12mg/kg once daily.
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Children under 5 years should be given medication for ADHD without a need for a second specialist opinion.
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Environmental modifications should not be implemented for children with ADHD.
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Methylphenidate is considered the first-choice medication for the treatment of ADHD.
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An electrocardiogram (ECG) is always required before starting stimulants for ADHD.
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Atomoxetine and guanfacine can be offered to children aged 5 years and over whose symptoms did not respond to methylphenidate or lisdexamfetamine.
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Height and weight monitoring is not necessary for children with ADHD on medication.
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If ADHD symptoms persist despite environmental modifications, medication should be offered after a baseline assessment.
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Lisdexamfetamine should not be considered for children who did not benefit from a 6-week trial of methylphenidate.
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A cardiology opinion should be sought if a child with ADHD has a history of sudden death in a first-degree relative under 40 years.
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Dexamphetamine should be considered for children whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate its longer effect profile.
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The onset of action for methylphenidate immediate release is between 20 and 60 minutes.
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Methylphenidate modified release has an initial daily dose of 35mg in the morning.
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Concerta XL consists of an immediate-release component that makes up 22% of the dose and a modified-release component making up 78%.
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An afternoon dose of methylphenidate immediate release is forbidden for children using modified-release methylphenidate.
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Equasym XL has an onset of action between 30 and 90 minutes.
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The licensed maximum dose of methylphenidate modified release is 54mg daily.
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Concerta XL has an initial dose of 20mg in the morning.
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Medikinet XL consists of an immediate-release component that constitutes 50% of the dose.
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For methylphenidate, dexamfetamine, and lisdexamfetamine, it is important to monitor blood pressure, pulse, height, and weight.
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Bioequivalent versions of Concerta XL include Matoride XL, Xenidate XL, and Delmosart modified release.
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Ritalin XL consists of an immediate-release component and a sustained-release component.
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Dexamfetamine immediate release has an onset of action that ranges from 20-60 minutes.
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The initial dosing recommendation for Lisdexamfetamine is between 30 and 40mg in the morning.
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Atomoxetine is classified as a noradrenaline reuptake inhibitor.
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For children weighing less than 70kg, the recommended maintenance dose of Atomoxetine is 80mg daily.
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Lisdexamfetamine is a prodrug that gradually hydrolyses to dexamfetamine.
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Atomoxetine is more effective than stimulants for treating ADHD.
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The maximum daily dose of Dexamfetamine is 20mg daily.
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Ritalin XL has an onset of 30 minutes and a duration of up to 6 hours.
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When switching from a stimulant to Atomoxetine, the stimulant should be continued for the first 4 weeks of Atomoxetine therapy.
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Study Notes
Diagnosis and Treatment of ADHD in Children
- A comprehensive assessment by a specialist is necessary to diagnose ADHD in children.
- A combination of psychological, psychosocial, and behavioral interventions should be used in treatment, with medication only used when necessary.
Medications for ADHD in Children
- Methylphenidate is the first-line treatment for ADHD in children when medication is required.
- Common adverse effects of methylphenidate include insomnia, appetite suppression, raised blood pressure, and growth deceleration.
- Dexamfetamine is an alternative CNS stimulant, but has less evidence on efficacy and safety than methylphenidate.
- Lisdexamfetamine is a prodrug that is gradually broken down in red blood cells, making it unlikely to be abused.
- Atomoxetine is a non-stimulant alternative that may be useful for children who do not respond to stimulants or have adverse effects.
Other Medications for ADHD in Children
- Alpha-2 agonists (clonidine and guanfacine) can be used as alternative non-stimulant medications.
- Bupropion seems to be efficacious and well-tolerated for ADHD in children.
- Modafinil has useful activity in children with ADHD, but not in adults.
- Tricyclic antidepressants may be effective, but are not recommended in clinical practice.
ADHD in Adults
- ADHD first diagnosed in adult life is compatible with ICD-11 and DSM-5.
- Medication is the first line of treatment for ADHD in adults, with the same principles as for children.
- Around 65% of patients with ADHD continue to meet full criteria or have achieved only partial remission by adulthood.
- A comprehensive assessment is necessary to diagnose ADHD in adults, including information from other informants and from adults who knew the patient as a child.
Medications for ADHD in Adults
- Methylphenidate, lisdexamfetamine, and atomoxetine are licensed for first-time use in adults with ADHD.
- Dexamfetamine can be used for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.
- Monitoring for symptoms of liver dysfunction and suicidal thinking is necessary for atomoxetine use in adults.
Guanfacine Dosage
- Initially, 1mg once daily for children weighing 6-12 kg, adjusted in steps of 1mg weekly.
- Maintenance dose: 0.05-0.12mg/kg once daily, with a maximum dose of 4mg.
- For children weighing 13-17 kg, initially 1mg once daily, adjusted in steps of 1mg weekly.
- Maintenance dose: 0.05-0.12mg/kg once daily, with a maximum dose of 4-7mg depending on weight.
Medication Onset and Duration
- Ritalin XL: onset 60 minutes, duration 8-12 hours.
- Dexamfetamine immediate release: onset 20-60 minutes, duration 3-6 hours.
- Lisdexamfetamine (Elvanse): onset 20-60 minutes, duration 13+ hours.
- Atomoxetine: onset approximately 4-6 weeks.
NICE Guidance for ADHD in Children
- Drug treatment for ADHD should be initiated by a specialist and only after a comprehensive assessment of mental and physical health, and social influences.
- Children under 5 years old should not be given medication unless they have a second specialist opinion from an ADHD service specializing in young children.
- There must be a group parent-training programme in place for all children under 5 years with ADHD.
- Environmental modifications should be implemented for all children with ADHD.
- Medication should be offered if there is a persistent significant impairment in a domain despite modifications, following a baseline assessment.
Medications for ADHD
- Methylphenidate (first-choice medication): onset 20-60 minutes, duration variable.
- Lisdexamfetamine: consider switching to this medication for children aged 5 years and over who have had a 6-week trial of methylphenidate at an adequate dose but have not derived enough benefit.
- Dexamfetamine: consider for children aged 5 years and older, and young people whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.
- Atomoxetine or guanfacine: offer to children aged 5 years and over, and young people that cannot tolerate methylphenidate or lisdexamfetamine, or whose symptoms were not responsive to a 6-week trial.
Monitoring and Prescribing
- Monitoring should include measurement of height and weight, recording of blood pressure, and heart rate.
- An electrocardiogram (ECG) is not needed before starting stimulants, atomoxetine, or guanfacine, unless the person has any specific cardiac conditions or risks.
- A cardiology opinion should be sought if any of the above apply.
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Description
Learn about the diagnosis and treatment of ADHD in children, including the importance of comprehensive assessment and combined interventions.
